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Neutropenic Enterocolitis Treatment & Management

  • Author: Keith Sultan, MD, FACG; Chief Editor: BS Anand, MD  more...
 
Updated: Nov 06, 2015
 

Approach Considerations

Patients with neutropenic enterocolitis must be monitored in an intensive care setting with serial abdominal examinations.

Use of recombinant granulocyte colony-stimulating factor (GCSF) may be considered in individual patients, depending on the clinical progression. Controlled trials using GCSF in this specific entity are lacking, although several case reports of a successful outcome have been reported in the literature. Moreover, a better understanding and definition of specific subsets of patients that may benefit from treatment or prevention of neutropenic enterocolitis is needed.

Joint management between medical and surgical teams is extremely important for a good outcome in patients with neutropenic enterocolitis.

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Medical Care

Although there are practice guidelines available,[29] no published randomized control trials comparing conservative medical therapy with surgical intervention in neutropenic enterocolitis exist; however, advocates for both types of therapy exist. The outcome appears to reflect the state of the underlying disease and other comorbidities at the time of clinical presentation rather than the treatment modality. Therefore, a uniform management strategy for neutropenic enterocolitis cannot be recommended. Individualize the approach to each patient. Early recognition of neutropenic enterocolitis in a patient who is neutropenic is paramount to a good outcome.

Conservative management includes the following:

  • Bowel rest and nasogastric suction
  • Close monitoring of patients using serial abdominal examinations in an intensive care setting
  • Intravenous fluids, blood, and platelet transfusions as necessary
  • Parenteral broad-spectrum antibiotics: Antibiotics should include agents covering enteric gram-negative and anaerobic organisms, including Clostridium species. Metronidazole may also be considered if pseudomembranous colitis cannot immediately be excluded.
  • Cultures: Obtain blood cultures for fungus, and consider early use of antifungal agents if the disease does not respond to antibiotics. [30]
  • Avoidance of certain medications: Anticholinergic agents, antidiarrheal drugs, and narcotics may worsen the condition or further confuse the clinical picture of neutropenic enterocolitis.

Diet and activity

Because the patient is fasting and on bowel rest, consider parenteral nutrition. Patients with neutropenic enterocolitis are usually extremely ill and in the intensive care setting on complete bed rest.

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Surgical Care

Immediate surgery has been proposed by Shamberger et al in patients with neutropenic enterocolitis with the following indications[15] :

  • Free intra-abdominal perforation
  • Clinical deterioration during conservative medical therapy
  • Differentiation from other acute abdominal conditions for which surgery is indicated
  • Unrelenting intra-abdominal sepsis or abscess formation
  • Continued hemorrhage with a platelet count and coagulation parameters within the reference range

Tailor the surgical procedure to the operative findings.

Choice of surgical procedures includes the following:

  • Cecostomy and drainage
  • A 2-stage right hemicolectomy or total abdominal colectomy, with or without a primary anastomosis
  • Defunctioning of the colon with a loop ileostomy

Normal-appearing serosal surfaces may conceal mucosal breakdown and necrosis. Therefore, resection should be extensive to assure removal of the diseased bowel.

Consider elective right hemicolectomy in patients who have required repeated courses of chemotherapy and who have responded to initial conservative medical therapy. Recurrent episodes of neutropenic enterocolitis have been reported in such patients.

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Contributor Information and Disclosures
Author

Keith Sultan, MD, FACG Assistant Professor of Medicine, Division of Gastroenterology, Hofstra North Shore-LIJ School of Medicine

Keith Sultan, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association

Disclosure: Nothing to disclose.

Coauthor(s)

Rajeev Vasudeva, MD Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine

Rajeev Vasudeva, MD is a member of the following medical societies: American College of Gastroenterology, Columbia Medical Society, South Carolina Gastroenterology Association, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, South Carolina Medical Association

Disclosure: Received honoraria from Pricara for speaking and teaching; Received consulting fee from UCB for consulting.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Additional Contributors

Robert J Fingerote, MD, MSc, FRCPC Consultant, Clinical Evaluation Division, Biologic and Gene Therapies, Directorate Health Canada; Consulting Staff, Department of Medicine, Division of Gastroenterology, York Central Hospital, Ontario

Robert J Fingerote, MD, MSc, FRCPC is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, Canadian Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Douglas M Heuman, MD, FACP, FACG, AGAF Chief of GI, Hepatology, and Nutrition at North Shore University Hospital/Long Island Jewish Medical Center; Professor, Department of Medicine, Hofstra North Shore-LIJ School of Medicine

Douglas M Heuman, MD, FACP, FACG, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, and American Gastroenterological Association

Disclosure: Novartis Grant/research funds Other; Bayer Grant/research funds Other; Otsuka Grant/research funds None; Bristol Myers Squibb Grant/research funds Other; Scynexis None None; Salix Grant/research funds Other; MannKind Other

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Ulcerative oral mucositis lesion on the lateral and ventral surfaces of the tongue.
Colonic pseudomembranes of pseudomembranous colitis. Photographs courtesy of Eric M. Osgard, MD.
Frontal abdominal radiograph in a patient with proved pseudomembranous colitis. Note the nodular haustral thickening, most pronounced in the transverse colon.
Perforated appendicitis with abscess; computed tomography scan. Note the appendicolith (arrow) and air within the abscess. The terminal ileum lies anterior to the appendiceal abscess, and inflammatory change is noted in its wall, which appears thickened (open arrow).
Plain abdominal radiograph in a 44-year-old man known to have long history of ulcerative colitis. The patient presented with an acute exacerbation of symptoms. Image shows thumbprinting in the region of the splenic flexure of the colon.
Typhlitis. Marked asymmetric cecal wall thickening (arrow) in a 64-year-old patient whose status is postchemotherapeutic for lymphoma.
Typhlitis. Marked circumferential cecal and ascending colon wall thickening (large arrows) with mild pericolonic inflammatory stranding (small arrows).
 
 
 
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